Using Natriuretic Peptide Blood Tests to Guide Heart Failure Treatment: What Works and What Doesn't

What the researchers found

The evidence for natriuretic peptide-guided therapy splits along several lines. In heart failure with reduced ejection fraction (HFrEF), the STARS-BNP and PROTECT trials demonstrated reduced cardiac events when medications were adjusted based on NP levels. Meta-analyses and the BATTLESCARRED and TIME-CHF studies showed mortality reduction specifically in patients under 75 years old.

However, the PRIMA and GUIDE-IT trials found no significant differences between NP-guided and conventional care. In heart failure with preserved ejection fraction (HFpEF) and in acute heart failure settings, NP-guided therapy showed no benefit over standard care. A promising application is in prevention: NP levels may help identify people at risk of developing heart failure and guide early intervention.

Why it matters

Heart failure is one of the leading causes of hospitalization and death worldwide. Using objective biomarker measurements to fine-tune treatment — rather than waiting for symptoms to worsen — could potentially improve outcomes. Understanding where NP-guided therapy works (younger patients with reduced ejection fraction) and where it doesn't (preserved ejection fraction, acute settings) helps clinicians use this tool appropriately rather than applying it universally.

How the study worked

This is a narrative review article that synthesizes results from multiple randomized controlled trials and meta-analyses examining natriuretic peptide-guided therapy in heart failure. Key trials analyzed include STARS-BNP, PROTECT, BATTLESCARRED, TIME-CHF, PRIMA, and GUIDE-IT. The review compares outcomes across different heart failure subtypes (HFrEF vs HFpEF), clinical settings (chronic vs acute), and patient demographics (age stratification).

What this study cannot tell us

This is a narrative review, not a systematic review or meta-analysis, so the study selection and interpretation may be subjective. The conflicting results across trials may reflect differences in NP targets, patient populations, medication protocols, and follow-up duration. The age-based benefit (under 75) identified in some studies may not generalize across all populations. The review focuses on BNP and NT-proBNP, not accounting for newer biomarkers that may complement NP-guided approaches.

How to read the evidence

This is a narrative review synthesizing multiple randomized controlled trials and meta-analyses. While the underlying evidence includes high-quality RCTs, the conflicting results across trials make the overall conclusions nuanced rather than definitive.

When this study was published

Published in 2022, this review covers trials spanning over a decade. The evidence landscape for NP-guided therapy has been relatively stable, though evolving heart failure treatments may shift the balance.

The bigger picture

Natriuretic peptides are among the most widely used peptide biomarkers in medicine, with BNP and NT-proBNP tests performed millions of times annually. The concept of biomarker-guided therapy — using molecular measurements to drive treatment decisions rather than waiting for clinical deterioration — is central to precision medicine. While the results for NP-guided therapy in heart failure are mixed, the principle of using peptide biomarkers to personalize treatment continues to evolve across cardiology, oncology, and other fields.

Questions still open

• Why does NP-guided therapy appear to benefit younger patients but not those over 75, and could age-specific NP targets address this?
• Could combining natriuretic peptide monitoring with other biomarkers improve outcomes in the patient populations where NP guidance alone falls short?
• As heart failure therapies evolve with new drugs like SGLT2 inhibitors, will NP-guided therapy become more or less relevant?

Common questions

Read the original research

Natriuretic Peptide-guided Therapy for Heart Failure.

Heart international, 16(2), 112-116

Citation

Horiuchi, Yu; Villacorta, Humberto; Maisel, Alan S. (2022). Natriuretic Peptide-guided Therapy for Heart Failure.. Heart international, 16(2), 112-116. https://doi.org/10.17925/HI.2022.16.2.112